Recent advances in percutaneous coronary intervention for modernizing coronary physiology-guided and device-based strategies for coronary revascularization

Coronary artery disease (CAD) remains a leading cause of morbidity and mortality worldwide. Over the past three decades, percutaneous coronary intervention (PCI) has evolved from a anatomical revascularization technique into a precision-based, physiology- and imaging-guided therapeutic strategy capable of addressing increasingly complex coronary disease. This review aims to critically examine contemporary advances in PCI, with particular emphasis on the integration of coronary physiology, intravascular imaging, and next-generation device technologies. We synthesize evidence from landmark randomized trials, meta-analyses, and recent high-impact studies to evaluate how these advances have reshaped clinical decision-making, procedural optimization, and long-term outcomes in complex coronary artery disease. A comprehensive narrative review of the literature was conducted using PubMed, Google Scholar, and the National Library of Medicine databases. The review focuses on physiology-guided PCI, drug-eluting stent evolution, intravascular imaging, PCI in complex clinical settings (including left main disease and post-coronary artery bypass grafting anatomy), and emerging adjunctive technologies. Structural interventions are discussed selectively to contextualize the broader evolution of catheter-based cardiovascular therapies. Contemporary PCI has been transformed by physiology-guided lesion assessment, advanced intravascular imaging, and improved stent platforms, enabling safer and more effective treatment of complex coronary anatomy. Evidence from recent trials highlights both the strengths and limitations of physiology-guided PCI, particularly in multivessel and post-CABG disease, underscoring the need for integrated anatomy-physiology approaches. Advances in device engineering, robotic assistance, and adjunctive pharmacotherapy have further refined procedural precision and outcomes. Emerging technologies, including drug-coated balloons, resorbable scaffolds, and innovative biologic and cell-free therapeutic strategies, illustrate the expanding translational landscape of coronary intervention. The modernization of PCI reflects a paradigm shift toward precision-guided, evidence-based coronary revascularization. While technological advances have broadened the scope of PCI and improved procedural outcomes, optimal revascularization strategies must remain individualized and grounded in robust clinical evidence.